“G’day doc. I’m a little embarrassed to bring this up but…”
“No worries, you know you can be honest here. Let’s check your blood pressure first. It was a bit high last time.”
“Oh… ok. Not dangerously high I hope?”
“Well it was just above the benchmark, which is concerning. As you know I don’t get paid if I don’t look after your pressure. Let’s see… 140 over 90. Uh oh. I’m afraid we have to bump up your medications.”
“But doc, could it be stress? I wanted to tell you that…”
“Stress, stress… That’s all well and good but Medicare doesn’t care what the cause is. If it’s too high I miss out. And if I miss out you miss out, you know that don’t you? We also have to talk about your weight target. As I’ve told you before, if you don’t lose those extra pounds our practice cannot afford to look after you any longer.”
“Are you listening to me? John and I broke up last night. I’m a mess!”
“I’m sorry to say that there’s no incentive payment for counselling anymore. Please do me a favour and book in for your pap smear on the way out. Last time you were late and we missed the deadline for our quarterly Medicare bonuses. We don’t want that to happen again do we?”
Generating consumer-led ideas to improve the health system – that’s what the Consumer Health Forum is all about, says new CEO Leanne Wells. Health consumerism around the world is changing, and Leanne sees a potential for big reforms in Australia. I asked her about a range of topics, including the Medicare rebate freeze, the RACGP draft vision for a sustainable health system, funding and the role of pharmacists.
“It is a terrific honour and challenge to be leading this organisation at a time of significant developments in the role of health consumerism globally,” she says. “I believe in a strong patient-clinician alliance.”
“Consumer leadership is as important as clinical leadership in developing modern health systems that reflect the importance of patient-centred care. We can achieve this by working together to influence policy settings, design and operation of health care.”
“Our members include a diverse range of consumer organisations as well as professional associations, researchers and individuals with an interest in health consumer affairs. Through our membership network, we reach millions of Australian consumers.”
“CHF is all about generating consumer-led ideas for a better health system. It is the pre-eminent national organisation advocating on behalf of health consumers on policy issues pertaining to Medicare, PBS and population health and on issues such as health system development, access to best available consumer-centred care and access to medications.
“CHF’s work has included research and national campaigns on rising out-of-pocket health costs and prescription medicine costs. We deal frequently with questions from media on issues such as health insurance and quality and safety in health care.”
“There is potential for significant changes in Australia’s health system, particularly in Commonwealth-financed areas such as Medicare, primary health care and mental health, at a time when there are moves to put focus on reforms to Commonwealth-State health funding issues. In all of these areas, consumer-generated ideas for a better system will be crucial to success.”
Medicare rebate freeze
“CHF has supported the RACGP and others in the campaign against the rebate freeze. Nothing should compromise good quality, comprehensive, co-ordinated patient care. I support the concept of the patient-centred healthcare home.”
“Some consumers have capacity to pay a co-payment and will do so if they feel they get value. Others simply won’t go to the doctor if they are not bulk billed – and often those who don’t go to the doctor due to cost barriers are those from lower socioeconomic circumstances which we know are associated with higher rates of complex, chronic conditions: the very conditions that need ongoing, co-ordinated care. The issue highlights the need for the MBS review and a rethink of the way we finance primary care. Both are long overdue.”
“General practices need the flexibility to be truly responsive to their patient populations
“CHF seeks funding that is determined by the right models of care, not the other way around. At the moment we’ve got a system that is largely based on fee-for-service financing to drive and, at times, limit models of care.”
“General practices need the flexibility to be truly responsive to their patient populations. The expansion of health insurance to primary practice, may offer benefits in terms of better integrated care for some. The overall impact however is likely to be negative, setting up a two-tiered health system at the primary care level where insured patients would be likely to get preferential treatment.”
“The RACGP’s draft consultation paper ‘Vision for a sustainable health system’ makes the case for an alternative blended payment model offering flexibility and autonomy to respond better to contemporary care needs. The paper would be stronger if it articulated a vision for general practice emphasising how that could be done.”
“The paper lacked consideration of aspects of integrated care and placed ‘general practice’ rather than ‘the patient’ at the centre of the health system. We would have liked the paper to place greater emphasis on the patient as partner and on the consumer benefits of team-based care as well as the other non-financial levers that can work in concert to bring about change and innovation in general practice.”
Consumers as partners
“A big challenge is for health care to be much more consumer-centred. That works best when there’s a team of professionals looking after the consumer, when there’s an open flow of information and discussion between them about the patient’s needs and how to meet them together rather than separately.”
“We want to see a patient-centred approach to providing care – not disease-centred or system-centred
“Above all else patients want professionals who see them as more than just the ‘vessel’ of a disease to be cured, or a problem to be solved. Patients want to be recognised for who they are: unique individuals with their own unique lives. We want to see a health workforce which takes a patient-centred approach to providing care – not disease-centred, not system-centred, but patient-centred.”
“The National Safety and Quality Health Service Standards have consumers as partners in care as its second standard – solid recognition that this value must become inherent to the culture and operation of health services. Primary Health Networks have a pivotal role in bringing this about.”
“Having worked with divisions of general practice and Medicare Locals since the 2000s, I remain a strong proponent of the place ‘meso’ structures like these have in the system. The Primary Health Networks have great promise as disruptive innovators in our system.”
“With their distinct boundaries, alignment with hospital networks, relationship with general practice and the knowledge they will grow about their local communities, they are well placed to work with patients and clinicians to lead service and system development and innovation.”
“But they can only do this if they have mandate, the support and participation of patients and clinicians and the financial flexibility to invest in new approaches and new models of care.”
Dysfunctional state-federal funding
“The CHF supports a single level of government taking responsibility for leadership in health policy. We are diverse country with distinct regional communities. I believe moving to a single level of government, with regional purchasers administering pooled funding, is a concept worth exploring further.”
“The only way we are going to integrate the system is by having policy set nationally, and service commissioning undertaken regionally by single entities. Integration has to be the name of the game given modern health care is about managing multi-morbidity and complexity. Removing the dysfunctional nature of state-federal funding would surely be an improvement on what we have now.”
Devaluation of general practice
“Patients need to be seen as partners in care – assets not deficits. I agree that general practice and its place in the health system has become devalued over time. It is a very efficient and effective setting in which to deliver care close to where consumers live and work.”
“I applaud the RACGP’s efforts to get general practice better recognised and valued
“I applaud the RACGP’s efforts to get general practice better recognised and valued. However, in the campaign video, the doctor is represented as the sage authority while the patients are represented as passive recipients of the doctor’s view of them and their lives.”
“The characterisation was at odds with all the evidence showing that approaches which encourage patient-centred and patient-engaged care produce better outcomes. This aspect of the doctor-patient relationship could have been better reflected.”
Pharmacists and General Practice
“CHF supports a stronger role for pharmacists in general practice in areas such as medication support. It would be in the patient’s interest for general practice to have non-dispensing pharmacists as part of the team available to advise on quality use of medicines, hopefully freeing up GPs to focus on time-consuming, complex cases requiring medical expertise.”
“Expanding the scope for dispensing pharmacists to provide medical advice in pharmacies would also be supported by CHF provided the role was strictly within the pharmacist’s qualifications, was coordinated with the patient’s GP or local GP and where necessary, the services performed in a private area. Both options are good ways to make better use of an existing valued workforce.”
Patients or consumers?
“There is a continuing debate on the patient-consumer dichotomy. We prefer the use of the word ‘consumer’ when talking in terms of the health system generally. In that context we think the word consumer more accurately expresses the non-dependent status of a citizen and customer of health services and products.”
“The word ‘patient’ is appropriate when referring to an individual under treatment of a clinician where the patient’s outcome is directly dependent on the clinician.”
“Health policy has proved, over the years, to be a bugbear for the Liberal Party. The Fraser Government had made numerous changes to its health policy, which had been both unsettling and politically damaging” ~ John Howard in Lazarus Rising
As they say, those who cannot remember the past are doomed to repeat it. Governments often make two mistakes when it comes to health policies:
It is driven by dollars instead of health outcomes
Advice from patients and health professionals is ignored
The current ‘health’ debate has, in reality, been a debate about the level of out-of-pocket expenses. The elephant in the room – more efficient funding – has been carefully avoided. We know there is too much waste and bureaucracy in the system – and many have argued the fee-for-service model is not ideal to manage chronic health problems.
If the Abbott Government is serious about tackling some of these issues, but wants to avoid the mistakes of the past, they should embrace the RACGP’s draft Vision for a sustainable health system. It is an opportunity to start a real healthcare debate.
The new model
As the draft document reiterates, health systems focusing on primary healthcare have lower use of hospitals and better health outcomes when compared to systems that focus on specialist care. It makes sense to fund a comprehensive range of services in primary care, based on local community needs.
The new vision proposes voluntary patient enrolment with a preferred practice to improve chronic care delivery and funding. It also recommends that current incentive payments are replaced by a payment system that facilitates the following five key activities:
Better integration of care
Supporting quality, safety and research
Team-based nursing care
Using IT and e-health to improve efficiency
Acute care and fee-for-service are still part of the package, but practices and GPs delivering ongoing comprehensive and complex care will be better rewarded in the new model. It will also assist practices and doctors looking after disadvantaged patient populations.
Much needed leadership
Earlier this year the RACGP invited members to comment on a first draft. Yesterday RACGP president Frank Jones presented the current version to Federal Health Minister Sussan Ley. It’s good to see the RACGP welcomes further feedback. Personally I am particularly interested in the response from patients and consumer organisations.
It seems the blended payment model reflects the increasing focus on chronic disease management, while still rewarding acute care. As always, the devil will be in the detail. But to be fair, this is a draft (and if you ask me, a good one).
By starting the discussion the RACGP is showing leadership. Let’s hope the Federal Health Minister is appreciative and brave enough to take on the challenge.